Healthcare Provider Details

I. General information

NPI: 1215167663
Provider Name (Legal Business Name): KRYSTAL VIGIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 W ABRIENDO AVE
PUEBLO CO
81004-1128
US

IV. Provider business mailing address

1302 CHINOOK LN
PUEBLO CO
81001-1851
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-545-4100
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-545-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: